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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880996
Report Date: 11/01/2021
Date Signed: 11/01/2021 03:06:34 PM

Document Has Been Signed on 11/01/2021 03:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TAMARIND SENIOR CARE, LLCFACILITY NUMBER:
361880996
ADMINISTRATOR:RAMAS, SOTERO CHANDLER IIIFACILITY TYPE:
740
ADDRESS:9545 TAMARIND AVETELEPHONE:
(909) 346-0292
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 3DATE:
11/01/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Sotero Chandler Ramas IIITIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown conducted an announced Case Management Visit to Tamarind Senior Care. LPA Brown explained to Administrator Sotero Chandler Ramas III that the Case Management Visit Report (LIC 809) completed today is in reference to complaint AS-20210823113426 and therefore the citation issued today (LIC 809D) also pertains to complaint AS-20210823113426.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that staff were not assisting R1 with administration of medications. LPA Brown obtained evidence to corroborate the allegation above. Staff reported that all client medications are centrally stored and administered according to their physician’s orders. However, LPA Brown learned that no medication records existed for R1. The facility was unable to provide LPA Brown with any documentation showing when R1’s medications were dispensed as prescribed by R1’s physician.

Based on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegation of staff not assisting resident with administration of medications is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. LPA Brown provided copies of both the LIC 809D as well as this report, LIC 809 to Administrator Ramas III.

***** LIC 809 pertains to complaint AS-20210823113426 *****
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2021 03:06 PM - It Cannot Be Edited


Created By: Melody Brown On 11/01/2021 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TAMARIND SENIOR CARE, LLC

FACILITY NUMBER: 361880996

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2021
Section Cited

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When requested by prescribing physician or the Department, a record of dosages of meds which are centrally stored... This requirement wasn't met as evidenced by: Based on observation, the licensee didn't maintain a record of centrally stored prescription meds for R1 for 1 year.
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***** LIC 809D pertains to complaint AS-20210823113426 *****
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2021


LIC809 (FAS) - (06/04)
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